HESI MODULE 8 QUESTIONS

HESI MODULE 8 QUESTIONS

1.Questions

1.1.ID: 9476967734

A nurse notes that the site of a client’s peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous near the insertion point of the catheter. On the basis of this assessment, the nurse should take which action first?

• Remove the IV catheter Correct
• Slow the rate of infusion
• Notify the health care provider
• Check for loose catheter connections

Rationale: Phlebitis is an inflammatory process in the vein. Phlebitis at an IV site may be indicated by client discomfort at the site or by redness, warmth, and swelling in the area of the catheter. The IV catheter should be removed and a new IV line inserted at a different site.Slowing the rate of infusion and checking for loose catheter connections are not correct responses. The health care provider would be notified if phlebitis were to occur, but this is not the initial action.Test-Taking Strategy: Note the strategic word, first. Focus on the data in the question. Eliminate slowing the rate of infusion and checking the connection, because they are comparable or alike in that they indicate continuation of IV therapy. Although the health care provider would be notified of this occurrence, the word “first” should direct you to select the option of removing the IV catheter. Review the signs of phlebitis and the actions to be taken when it occurs

Level of Cognitive Ability: Applying

Client Needs: Physiological Integrity

Integrated Process: Nursing Process/Implementation

Content Area: Intravenous Therapy

Giddens Concepts: Clinical Judgment, Inflammation

HESI Concepts: Clinical Decision-Making/Clinical Judgment, Inflammation

Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8 th

ed., p. 707). St. Louis: Mosby.

Awarded 1.0 points out of 1.0 possible points.

2.2.ID: 9476963098

A nurse hangs a 500-mL bag of intravenous (IV) fluid for an assigned client. One hour later the client complains of chest tightness, is dyspneic and apprehensive, and has an irregular pulse.The IV bag has 100 mL remaining. Which action should the nurse take first?

• Remove the IV
• Sit the client up in bed
• Shut off the IV infusion Correct
• Slow the rate of infusion

Rationale: The client’s symptoms are indicative of speed shock, which results from the rapid infusion of drugs or a bolus infusion. In this case, the nurse would note that 400 mL has infused over 60 minutes. The first action on the part of the nurse is shutting off the IV infusion.Other actions may follow in rapid sequence: The nurse may elevate the head of the bed to aid the client’s breathing and then immediately notify the health care provider. Slowing the infusion rate is inappropriate because the client will continue to receive fluid. The IV does not need to be removed. It may be needed to manage the complication.Test-Taking Strategy: Note the question contains the strategic word “first.” Recognizing the signs of speed shock and recalling the appropriate interventions should also direct you to the option of shutting off the IV infusion. Review the initial nursing actions for speed shock

Level of Cognitive Ability: Applying

Client Needs: Physiological Integrity

Integrated Process: Nursing Process/Implementation

Content Area: Critical Care

Giddens Concepts: Fluid and Electrolytes, Perfusion

HESI Concepts: Fluid and Electrolytes, Perfusion

Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7 th

ed., p. 230). St. Louis: Saunders.

Awarded 1.0 points out of 1.0 possible points.

3.3.ID: 9476961248

A nurse discontinues an infusion of a unit of packed red blood cells (RBCs) because the client is experiencing a transfusion reaction. After discontinuing the transfusion, which action should the nurse take next?

• Remove the IV catheter
• Contact the health care provider Correct
• Change the solution to 5?xtrose in water
• Obtain a culture of the tip of the catheter device removed from the

client Rationale: If the nurse suspects a transfusion reaction, the transfusion is stopped and normal saline solution infused at a keep-vein-open rate pending further health care provider prescriptions. The nurse then contacts the health care provider.. Dextrose in water is not used, because it may cause clotting or hemolysis of blood cells. Normal saline solution is the only type of IV fluid that is compatible with blood. The nurse would not remove the IV catheter, because then there would be no IV access route through which to treat the reaction. There is no reason to obtain a culture of the catheter tip; this is done when an infection is suspected.Test-Taking Strategy: Note the strategic word “next.” Knowing that the IV should not be removed will assist you in the elimination process. Recalling that normal saline solution is the only type of IV fluid that is compatible with blood will also help you answer correctly. To select from the remaining options, note that infection is not the concern; this will help you eliminate the option of obtaining a culture of the catheter tip. Review care of the client experiencing a transfusion reaction

Level of Cognitive Ability: Applying

Client Needs: Physiological Integrity

Integrated Process: Nursing Process/Implementation

Content Area: Blood administration

Giddens Concepts: Clinical Judgment, Perfusion

HESI Concepts: Clinical Decision-Making/Clinical Judgment, Perfusion

Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8 th

ed., pp. 740-741). St. Louis: Mosby.

Awarded 1.0 points out of 1.0 possible points.

4.4.ID: 9476963017

The nurse determines that the client is exhibiting signs of a hemolytic transfusion reaction while receiving a blood transfusion. The nurse should perform these actions in which priority order? Arrange the actions in the order that they should be performed.All options must be used.Correct

• Stopping the infusion of blood
• Hanging an IV bag of normal saline solution (NS) at a keep-vein-open

(KVO) rate

• Notifying the health care provider
• Obtaining vital signs/oxygen saturation
• Documenting the findings

Rationale: If a transfusion reaction is suspected, the transfusion is immediately stopped and NS infused, pending further primary health care provider prescriptions. Ensuring patent IV access also helps maintain the client’s intravascular volume. NS is the solution of choice, rather than solutions containing dextrose, because red blood cells do not clump with NS. Next, the primary health care provider should be notified because this is an emergency situation. Vital signs and oxygen saturation are monitored closely. Finally, the nurse documents the findings and the client’s response to the interventions.Test-Taking Strategic: Note the strategic word, priority. Note that the client is experiencing a hemolytic transfusion reaction an emergency condition. The question sets forth the problem; the nurse must determine the order in which interventions should be performed. First, the blood transfusion is stopped and an isotonic solution infused. Next the nurse should notify the primary healthcare provider, check vital signs and oxygen saturation data, and assess the client closely. Once prescriptions from the primary healthcare provider have been initiated, the nurse should document the event and client’s response. Review the prioritization of interventions for a transfusion reaction

Level of Cognitive Ability: Applying

Client Needs: Physiological Integrity

Integrated Process: Nursing Process/Implementation

Content Area: Blood Administration

Giddens Concepts: Care Coordination, Clinical Judgment

HESI Concepts: Clinical Decision-Making/Clinical Judgment, Collaboration/Managing Care – Care Coordination Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th

ed., pp. 740-741). St. Louis: Mosby.

Awarded 1.0 points out of 1.0 possible points.

2.5.ID: 9476964571

A client with heart failure is being given furosemide and digoxin. The client calls the nurse and complains of anorexia and nausea. Which action should the nurse take first?

• Administer an antiemetic
• Administer the daily dose of digoxin
• Discontinue the morning dose of furosemide
• Checkthe result of laboratory testing for potassium on the sample

drawn 3 hours ago Correct Rationale: Anorexia and nausea are symptoms commonly associated with digoxin toxicity, which is compounded by hypokalemia. Early clinical manifestations of digoxin toxicity include anorexia and mild nausea, but they are frequently overlooked or not associated with digoxin toxicity. Hallucinations and any change in pulse rhythm, color vision, or behavior should be investigated and reported to the health care provider. The nurse should first check the results of the potassium level, which will provide additional when the nurse calls the health care provider,an important follow-up action. The nurse should also check the digoxin reading if one is available. The nurse would not administer an antiemetic without further investigating the client’s problem. Because digoxin toxicity is suspected, the nurse would withhold the digoxin until the health care provider has been consulted. The nurse would not discontinue a medication without a prescription to do so.Test-Taking Strategy: Note the strategic word “first” and use the steps of the nursing process to answer the question. The correct option is the only one that addresses assessment. Review nursing interventions for suspected digoxin toxicity

Level of Cognitive Ability: Applying

Client Needs: Physiological Integrity

Integrated Process: Nursing Process/Implementation

Content Area: Pharmacology

Giddens Concepts: Cellular Regulation, Clinical Judgment

HESI Concepts: Cellular Regulation, Clinical Decision-Making/Clinical Judgment

References: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (p. 363)

St. Louis: Saunders.

Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7 th

ed., p. 753). St. Louis: Saunders.

Awarded 1.0 points out of 1.0 possible points.

2.6.ID: 9476961282

The health care provider (HCP)prescribes the administration of totalparenteral nutrition (TPN), to be started at a rate of 50 mL/hr by way of infusion pump through an established subclavian central line. After the first 2 hours of the TPN infusion, the client suddenly complains of difficulty breathing and chest pain. The nurse should take which immediate action?

• Obtain blood for culture
• Clamp the TPN infusion line Correct
• Obtain an electrocardiogram (ECG)
• Obtain a sample for blood glucose testing